Potentially fatal hemorrhagic duodenal ulcers caused by cytomegalovirus infection complicating autoimmune hepatitis with acute liver failure, successfully treated with multiple interventional radiology procedures.
Satoshi Sato, Yusuke Matsuoka, Hidezumi Kikuchi et al.
✦ AI-curated · Sources linked
Case in brief
A patient treated with steroid pulse therapy for acute-onset autoimmune hepatitis progressed to acute liver failure. Liver failure improved after plasma exchange and continuous hemodiafiltration, but multiple duodenal ulcers developed after azathioprine was introduced and were attributed to CMV reactivation. One ulcer caused a microperforation that resolved with conservative management. The patient then developed bleeding from multiple gastrointestinal sites, and endoscopic hemostasis was difficult. Because the patient was too unwell for surgery, interventional radiology was performed three times in one day, achieving hemostasis and saving the patient’s life.
What made this case unusual
The combination of CMV-associated multiple duodenal ulcers, microperforation, and bleeding at multiple sites made endoscopic control difficult; repeated interventional radiology procedures provided hemostasis when surgery was not feasible.
Diagnostic / clinical pearl
In acute liver failure during immunosuppressive treatment for autoimmune hepatitis, remain alert to CMV reactivation as a cause of gastrointestinal ulceration and hemorrhage.
Why it matters
This case illustrates that interventional radiology may be used repeatedly to control gastrointestinal bleeding when endoscopic hemostasis is difficult and the patient cannot undergo surgery.